Neurology - stroke Flashcards
What are strokes caused by?
Ischaemia or infarction due to inadequate blood supply
Intracranial haemorrhage
What can cause disruption of blood supply leading to stroke?
Thrombus formation or embolus, for example in patients with atrial fibrillation
Atherosclerosis
Shock
Vasculitis
Presentation of stroke
Sudden onset of neurological symptoms.
Symptoms are typically asymmetrical:
Sudden weakness of limbs
Sudden facial weakness
Sudden onset dysphasia (speech disturbance)
Sudden onset visual or sensory loss
RFs for stroke
Cardiovascular disease such as angina, myocardial infarction and peripheral vascular disease
Previous stroke or TIA
Atrial fibrillation
Carotid artery disease
Hypertension
Diabetes
Smoking
Vasculitis
Thrombophilia
Combined contraceptive pill
Investigations in suspected stroke
CT head - to exclude intracerebral haemorrhage
Exclude hypoglycaemia and other stroke mimics - but don’t delay the CT head if stroke is likely
Could consider carotid ultrasound (not in the acute scenario so much) - to assess for carotid stenosis
Bloods
What are some stroke mimics?
Seizure (e.g. Todd’s paresis following seizure)
Hypoglycaemia
Migraine (particularly hemiplegic migraine)
Syncope
Initial management of stroke
Aspirin 300mg stat (after CT excluded haemorrhage) - for 2 weeks
Thrombolysis with alteplase (after haemorrhage excluded) - can be offered within 4.5h of symptom onset
Thrombectomy is also an option if an occlusion is confirmed on imaging and within 24h of symptom onset.
Generally, blood pressure should not be lowered during a stroke because this risks reducing the perfusion to the brain.
How does alteplase work?
It is a tissue plasminogen activator that rapidly breaks down clots
What are some absolute contraindications to thrombolysis?
- Previous intracranial haemorrhage -
- Uncontrolled hypertension >200/120mmHg
- Active bleeding
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Pregnancy
- Oesophageal varices
Management of TIA
Start aspirin 300mg daily. Start secondary prevention measures for cardiovascular disease.
Stroke specialist review within 24h
What is the secondary prevention of stroke?
Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily)
Atorvastatin 80mg should be started but not immediately
Carotid endarterectomy or stenting in patients with carotid artery disease
Treat modifiable risk factors such as hypertension and diabetes
Further long term stroke management
MDT involvement including:
- SALT
- Dieticians
- Physio
- Nurses
- OT
- Ophthalmology
- Orthotics
